CLASSIFICATIONS. Established in 1994 as a subcommittee of the. Prosthodontic Care Committee

CLASSIFICATIONS Established in 1994 as a subcommittee of the Prosthodontic Care Committee

Committee Members Thomas J. McGarry, DDS, Chair Arthur Nimmo, DDS James F. Skiba, DDS Christopher R. Smith, DDS Robert H. Ahlstrom, DDS, MS Jack H. Koumjian, DDS, MSD Ronald P. Desjardins, DMD, MSD

The value of information and the cost of uncertainty: Who pays the bill? Lysle E. Johnston, Jr. DDS, Ph.D. The Angle Orthodontist Vol. 68 No 2 1998 In the long run, a willingness to treat without reference to evidence has a price that can be measured. Stated simply, it is the difference between what the patient actually gets and what he or she could have gotten from the best available treatment. The cost of this difference (the regret ) always comes due and is borne in full by the patient.

Perhaps because there is no obvious penalty for being wrong (or for not being as right as one might like), decision-making in the face of uncertainty (i.e., in the absence of data) is a time-honored prosthodontic tradition.

Diagnostic Classification of Complete Edentulism

Do different physical variations require a change in treatment procedures? Do different treatment procedures require additional education and training? Do patient mediated variables require a change in treatment procedure?

Evidence based treatment procedures require: Accurate diagnosis Differentiation of treatment procedures to a specific diagnosis Outcome assessment criteria

EDENTULOUS EDENTULISM

PHYSIOLOGY OR ABUSE? Resorption Increased osteoclastic activity, as in hyperparathyroidism and pressure mediated resorption

Establish the continual resorption/atrophy for the majority of edentulous patients Increasing dysfunction Residual Ridge Reduction Maxilla 0.1mm Mandible 0.4mm

Chronic progressive, irreversible and disabling disease process probably of multifactoral origin. At the present time, the relative importance of various cofactors is not known.

TREATMENT PROCEDURES PARAMETERS OF CARE SPECIALTY PROCEDURES CODING GENERAL CODING OUTCOME DATA CRITERIA PARAMETERS OF CARE SUCCESS COMPLICATIONS & KNOWN RISKS PARAMETERS OF CARE REVISION

DEFINITION OF SPECIALTY Diagnostic Coding Committee Computerized Patient Record Parameters of Care Outcome Data Assessment Quality Assurance Third Party Coverage Peer Review

American College of Pathologists SNOMED

Dental Diseases SNODENT

Diagnostic Code +Treatment Code Outcome Data

Complete Edentulism

Class I Ideal or minimally compromised Classification System for the Completely Edentulous Patient Class II Class III Moderately compromised Substantially compromised Diagnostic Criteria 1. Bone height--mandibular 2. Maxillomandibular relationship 3. Residual ridge morphologymaxilla 4. Muscle attachments Class IV Severely compromised

Diagnostic Criteria Addendum The diagnostic criteria are ordered by their objective nature and not in their rank of significance. Objective criteria will allow for the most accurate application of the classification system and measurement of its efficacy. Objectivity will also provide reliable outcome data and mechanisms for review by administrative panels.

Bone Height Mandibular

Quantity of the Underlying Bony Foundation Denture foundation area Tissues remaining for reconstruction Loss of facial muscle support/attachment Decrease in total facial height Residual ridge morphology

Classification of Alveolar Atrophy John H. Kent, D.D.S. LSU Medical Center, New Orleans Alveolar measurements Incisal edge to vestibule 19mm Alveolar crest to vestibule 10mm

Alveolar Measurements Occlusal plane to inferior border Mental nerve to inferior border Alveolar crest to inferior border 40mm 15mm 32mm

The objectivity of residual bone height measurement is affected by the magnification and variance of radiographic procedures and equipment of different manufacturers.

However, this diagnostic measurement reveals the most information of all the criteria. In order to minimize variance in techniques, the measurement should be made at that portion of the mandible of the least vertical height.

Type I Residual bone height of 21mm or greater measured at the least vertical height of the mandible.

Type II Residual bone height of 16-20 mm measured at the least vertical height of the mandible.

Type III Residual alveolar bone height of 11-15 mm measured at the least vertical height of the mandible

Type IV Residual vertical bone height of 10 mm or less measured at the least vertical height of the mandible

Functional Positioning of the Artificial Teeth Maxillomandibular relationship classification relates to the position of the artificial teeth to the residual ridge and to the opposing dentition.

Maxillomandibular Relationship

Class I Maxillomandibular relationship allows tooth position that has normal articulation with the teeth supported by the residual ridge.

Class II Maxillomandibular relationship requires tooth position outside the normal ridge relation in order to attain phonetics and articulation; i.e., anterior or posterior tooth position not supported by the residual ridge/anterior vertical overlap that exceeds the principles of articulation.

Class III Maxillomandibular relationship requires tooth position outside the normal ridge relation in order to attain phonetics and articulation; i.e., crossbite anterior or posterior, tooth position not supported by the residual ridge.

Complete Edentulism

Position and Angulation of the Occlusal Plane

Residual Ridge Morphology: Maxilla Residual ridge morphology is the most objective criteria for the maxilla since measurement of the residual bone height by radiography is not reliable. The following descriptive scenario follows a logical progression to describe the effects of residual ridge morphology and muscular influence on the maxillary denture.

Type A Maxilla Hard Palate form Anterior Maxilla Maxillary Tuberosities

Anterior labial and posterior buccal vestibular depth that resists vertical and horizontal movement of the denture base Palatal morphology that resists vertical and horizontal movement of the denture base Sufficient tuberosity definition that resists vertical and horizontal movement of the denture base Hamular notch is well defined to establish the posterior extension of the denture base Absence of tori or exostoses

Type B Maxilla Hard Palate form Residual Alveolar Ridge Anterior Posterior Maxillary Tuberosities

Loss of posterior buccal vestibule Tuberosity and hamular notch are poorly defined compromising delineation of the posterior extension of the denture base Maxillary palatal and/or lateral tori are rounded and do not affect the posterior extension of the denture base Palatal vault morphology that resists vertical and horizontal movement of the denture base

Type C Maxilla Hard Palate form Anterior Maxilla Maxillary Tuberosities

Loss of anterior labial vestibule Prominent midline suture Maxillary palatal and/or lateral tori with bony undercuts that do not affect the posterior extension of the denture base Hyperplastic, mobile anterior ridge that offers minimum support and stability of the denture base Palatal vault morphology that offers minimal resistance to vertical and horizontal movement of the denture base Reduction of the post malar space by the coronoid process during mandibular opening and/or excursive movements

Type D Maxilla Hard Palate form Residual alveolar ridge Anterior Posterior Maxillary Tuberosities

Loss of anterior labial and posterior buccal vestibules Maxillary palatal and/or lateral tori-rounded or undercut- that interferes with the posterior border of the denture Hyperplastic, redundant anterior ridge Palatal vault morphology that does not resist vertical or horizontal movement of the denture base Prominent anterior nasal spine

The location and influence of the muscle attachments affecting a complete denture are most commonly associated with the mandibular denture. Although, arguably the most significant measurement, it is also the most difficult to quantify.

The following descriptive scenario follows a logical progression to describe the effects of muscular influence on the mandibular denture.

Anatomy that resists anterior (forward) movement of the denture base

Muscle Attachments

Type A Adequate attached mucosal base without undue muscular impingement during normal function in all regions.

Type B Adequate attached mucosal base in all regions except anterior buccal vestibule cuspid to cuspid High mentalis muscle attachment

Type C Adequate attached mucosal base in all regions except anterior buccal and lingual vestibules cuspid to cuspid High genioglossus and mentalis muscle attachments

Type D Adequate attached mucosal base only in the posterior lingual region All other regions are detached

Type E No attached mucosa in any region Cheek and lip movement = tongue movement

Diagnostic Classification of Complete Edentulism

Class I This classification level describes the stage of edentulism that is most apt to be successfully treated by conventional prosthodontic techniques with complete denture prosthesis. All four of the diagnostic criteria are favorable.

Class I Residual bone height of 21 mm or greater measured at the least vertical height of the mandible Class I maxillomandibular relationship

Residual ridge morphology that resists horizontal and vertical movement of the denture base Type A Maxilla Location of muscle attachments that are conducive to denture base stability and retention Type A, B--Mandible Class I

Class II This classification level distinguishes itself with the noted continuation of the physical degradation of the denture supporting structures and in addition is characterized with the early onset of systemic disease interactions, localized soft tissue factors and patient management/lifestyle considerations.

Residual bone height of 16-20 mm measured at the least vertical height of the mandible Class II Class I maxillomandibular relationship Residual ridge morphology that resists horizontal and vertical movement of the denture base Type A, B--Maxilla

Location of muscle attachments with limited influence on denture base stability and retention Type A,B Mandible Class II Minor modifiers, psychosocial considerations, mild systemic disease with oral manifestations and localized soft tissue conditions

Class III This classification level is characterized by the need for surgical revision of denture supporting structures to allow for adequate prosthodontic function. Additional factors now play a significant role in treatment outcomes.

Residual bone height of 11-15 mm measured at the least vertical height of the mandible Class III Class I, II and III maxillomandibular relationship Residual ridge morphology has minimum influence to resist horizontal or vertical movement of the denture base Type C Maxilla Location of muscle attachments with moderate influence on denture base stability and retention Type C--Mandible

Conditions requiring preprosthetic surgery: Minor soft tissue procedures Minor hard tissue procedures Implant placement (simple)--no augmentation required Multiple extractions leading to complete edentulism for immediate denture placement Limited interarch space 18-20 mm Moderate psychosocial considerations and/or moderate oral manifestations of systemic diseases or localized soft tissue conditions TMD symptoms present Large tongue with or without hyperactivity Hyperactive gag reflex

Class IV This classification level depicts the most debilitated edentulous condition. Surgical reconstruction is almost always indicated but can not always be accomplished due to the patient s health, desires, past dental history and financial considerations. When surgical revision is not selected, prosthodontic techniques of a specialized nature must be used in order to achieve an adequate treatment outcome.

Residual bone height of least vertical height of the mandible Class IV Class I, II and III maxillomandibular relationships Residual ridge offers no resistance to horizontal or vertical movement Type D Maxilla Location of muscle attachments with significant influence on denture base stability and retention Type D and E--Mandible

Major conditions which require preprosthetic surgery Implant placement (complex) augmentation required Surgical correction of dentofacial deformities Hard tissue augmentation Major soft tissue revision, i.e., vestibular extensions with or without soft tissue grafting History of paresthesia or dysensthesia Insufficient interarch space with surgical correction required Acquired or congenital maxillofacial defects

Severe oral manifestation of systemic disease or conditions including sequelae from oncologic treatment Maxillomandibular ataxia (incoordination) Hyperactivity of tongue that can be associated with a retracted tongue position and/or its associated morphology Hyperactive gag reflex managed with medication Psychosocial conditions warranting professional intervention

Refractory patient (a patient who has chronic complaints following appropriate therapy). These patients continue to have difficulty in achieving their treatment expectations despite the thoroughness or frequency of the treatment provided.

Guidelines for use of the Complete Edentulism Classification System In those instances when a patient s diagnostic criteria are mixed between two classes, any single criteria of a more complex class will move the patient into that respective class. Utilization of this system is indicated for pre-treatment evaluation and classification of patients. Retrospective analysis on a post-treatment basis may alter a patient s final classification

Recognition by third-party payers of these special procedures and techniques Establish codes for procedures Establish codes for groups of procedures Establish that prosthodontists are the most common users of these codes/procedures

Target Audiences for this Edentulous Classification System Prosthodontic Educators Prosthodontic Researchers Prosthodontic Clinicians General Practitioners Oral & Maxillofacial Surgeons Third Party Payers Closed Panel Administrators

Improve Communication within Specialty Common language Standardize research Standardize terminology

Specialties with Classifications Systems Orthodontics Periodontics Oral and Maxillofacial Surgery Endodontics

Prosthodontic Classification System Being developed by the ACP for edentulous, partially edentulous and dentate patients Based upon diagnostic findings rather than treatment methods Education will decide what level is appropriate for the new dentist

The Next Step? Implementation of the Prosthodontic Classification System Outcome assessment measures for procedures at the competency skill level

Objective Criteria for Treatment Difficulty What makes a difficult patient? Measurable criteria Hard tissue Soft tissue Maxillomandibular relationship